Viral

Hepatitis
April Love R. Oja, RN, MAN
 Viral Hepatitis

Hepatitis means inflammation of the liver. The liver is a vital

organ that processes nutrients, filters the blood, and fights
infections. When the liver is inflamed or damaged, its
function can be affected. Heavy alcohol use, toxins, some
medications, and certain medical conditions can cause
hepatitis. However, hepatitis is often caused by a virus.

To date, five definitive types of viral hepatitis

that cause liver disease have been identified:
hepatitis A, B, C, D,and E. Hepatitis A and E
are similar in mode of transmission (fecal–
oral route), whereas hepatitis B, C, and D
share many other characteristics.
 Important Properties of Hepatitis Viruses
HAV HBV HCV HDV HEV

•ssRNA •dsDNA •ssRNA •ssRNA •ssRNA

•(+) DNA
•nonenveloped polymerase in
•Enveloped •Enveloped virus •Nonenveloped
•Picornavirus virion •Flavirus Family •Defective •Calicvirus
•FECAL-ORAL •(+) HBs Ag in •BLOOD, SEX, replication Family
envelope
ROUTE PERINATAL •Deltavirus Family •FECAL-ORAL
•Hepadnavirus
Family •BLOOD, SEX, ROUTE
•BLOOD, SEX, PERINATAL
PERINATAL
 Clinical Presentation and Outcomes
HAV HBV HCV HDV HEV

ONSET abrupt insidious insidious insidious abrupt

INCUBATION 15-50 28-160 14-160 30-180 15-60

PERIOD
(DAYS)
CHRONIC No Yes Yes Yes Yes, but
HEPATITIS exclusively
among
immunocompro
mised persons

SEVERITY OF Mild Moderate Mild Can be severe Severe in

ACUTE Pregnant
DISEASE women
Pathophysiology
Hepatitis viruses replicate in the liver

Direct action of the virus on the liver /

Activation of cell-mediated immune response

Destruction of hepatocytes

Hyperplasia, necrosis, cellular regeneration

Mild inflammatory process: liver parenchyma

is not significantly damaged

Severe inflammatory process : severe liver

damage
 Vaccine Availability
HAV HBV
• Preexposure Prophylaxis • Preexposure prophylaxis
• Hepatitis A vaccine • HBV vaccine (0, 1, 6 months) via
• Post exposure prophylaxis deltoid muscle
• Hepatitis Vaccine • Anti-HBs screening
• Hepatitis Immune Globulin- 1-2 • Postexposure prophylaxis
months passive immunity, given • HBIG within 24 hours
within two weeks after exposure

HCV HDV HEV

• No vaccine available • Hepa B vaccine • No FDA approved
vaccine for HEV in the
US but a recombinant
vaccine is available for
use in China
 Clinical Manifestation
Incubation

Prodromal

Icteric

Recovery Phases
 Incubation Phase

The virus is replicating and

manifestations vary depending on
the virus.

There may be no symptoms, but

there can be serologic and serum
enzyme markers
 Prodromal Phase

Fatigue Anorexia Malaise Nausea Vomiting

Headache Hyperalgia Cough Low-grade

fever
Icteric Phase
 Icteric Phase
• due to excess bilirubin being excreted by
Dark urine the kidneys

Clay colored • if conjugated bilirubin cannot pass into the

intestines from the liver because of
stools obstruction or inflammation of the bile ducts

Hepatomegaly • Ongoing inflammation

 Icteric Phase
• results from a change in normal
bilirubin metabolism or disruption of
Jaundice the flow of bile into the hepatic or
biliary duct systems

• accumulation of bile salts beneath the

Pruritus skin
 Recovery Phase
Begins with the resolution of jaundice
about 6-8 weeks post exposure.

Although the liver may still be enlarged

and tender, symptoms diminish

Liver function tests results return to

normal within 2 to 12 weeks after the
onset of jaundice
 Diagnostic Findings
HAV • Anti-HAV antibodies present

• Positive HBsAg (HBV surface antigen); anti-

HBV HBV antibodies present

HCV • Anti-HCV antibodies present, HCV-RNA

• Positive HDVAg (delta antigen) early; anti-

HDV HDV antibodies later

HEV • Anti-HEV antibodies present

 Diagnostic Findings
Alkaline phosphatase
• Moderately ↑ : impaired excretory
function of the liver

Y- glutanyl
transpetidase (GGT) • ↑: liver cell injury

Aspartate
• ↑ in acute phase; decreases as
aminotransferase
(AST) jaundice disappears

Alanine • ↑ in acute phase, decreases as

aminotransferase (ALT) jaundice disappears
 Diagnostic Findings

Albumin • Normal or ↓

Total • Increased to about 8-15

bilirubin mg/dL: liver cell injury

Urinary • ↑ : conjugated
bilirubin hyperbilirubinebmia
 Complications
Chronic hepatitis Ascites and
ALT, AST
lower extremity Asterixis
elevations
• is chronic infection of edema

the liver. HBC, HCV and

HDV Bleeding Hepatic
Fatigue, malaise
• Liver function tests abonormalities encephalopathy
remain abnormal for
longer than 6 months
• the primary cause of Increased
bilirubin
Jaundice
Myalgias and
arthralgias
liver damage leading to
cirrhosis, liver cancer
and liver Palmar
transplantation. erythema
Spider angiomas
 Complications
Fulminant Disseminated
hepatitis Encephalophathy GI Bleeding intravascular
coagulation (DIC)

• is a rapidly
Renal
progressive Fever with manifestations
Ascites
leukocytosis (oliguria and
disease, with azotemia)
liver failure
developing Edema Hypotension Respiratory failure
within 2 to 3
weeks after the
onset of Thrombocytopenia
Hypoglycemia Bacterial infections and
symptoms. coagulopathies
 Complications
HAV HBV, HCV HDV HEV

• Rare • Chronic • Chronic • It can

• Self- Hepatitis Hepatitis cause
limiting • Fulminant • Cirrhosis fulminant,
hepatitis • Fulminant fatal
• Cirrhosis hepatitis hepatitis
in
• Liver
pregnant
Cancer
women.
 Carrier State

HAV HBV HCV HDV HEV

• No • Yes • Yes • Yes • Yes
Chronic Hepatitis / Complications
 HAV: Medical Management
Supportive Care

• Bed rest during the acute stage and a nutritious diet are
important aspects of treatment.
• frequent small feedings, supplemented if necessary by IV
fluids with glucose.
• Optimal food and fluid levels are necessary to counteract
weight loss and to speed recovery.
• The patient’s sense of well-being and laboratory test
results are generally appropriate guides to bed rest and
restriction of physical activity.
• Gradual but progressive ambulation hastens recovery,
provided the patient rests after activity and does not
participate in activities to the point of fatigue.
 HBV: Medical Management
Pharmacologic Therapy

• Alpha Interferron
• Pegylated Interferron
• Antiviral Drugs: Entecavir and Tenofovir

Supportive Care

• Bed rest may be recommended until the symptoms of hepatitis

have subsided. Activities are restricted until the hepatic
enlargement and levels of serum bilirubin and liver enzymes have
decreased. Gradually, increased activity is then allowed.
• Protein intake should be 1.2 to 1.5 g/kg/day.
• Antacids and antiemetics
 Medical Management of HCV & HDV
Pharmacologic Treatment of HCV

• Simeprevir (Olysio) plus sofosbuvir (Sovaldi),

ledipasvirsofosbuvir (Harvoni) and ombitasvir-paritaprevir-
ritonavir packaged with dasabuvir (Viekira Pak)
• Peginterferon (Pegasys) and ribavirin

Pharmacologic Treatment of HDV

• No treatment is available for HDV infection specifically.

Pegylated interferon alpha has shown some efficacy, but
the sustained virologic response rate (a measure of viral
clearance) is low (25%) (12).
 HEV: Medical Management
Supportive Approach

• Resolves on its own without treatment.

Rest, get adequate nutrition and fluids,
avoid alcohol, and check with their
physician before taking any
medications that can damage the liver,
especially acetaminophen.
• Hospitalization in severe cases,
pregnant women.
 Nursing Management
Planning and Implementation
• Promote rest
• Maintain physical rest alternating with periods of activity
to promote liver cell generation by reducing the liver’s
metabolic needs.
• Individualize the patient’s plan of care and change it to
reflect the severity of symtpoms, fatigue, and the results
of liver function tests and enzyme determination.
• Provide diet therapy. Diet should be high in carbohydrates
and calories with moderate amounts of fat and protein
• Determine food preferences
• Provide small, frequent meals and high-calorie snacks
as needed.
• Liver transplantation may be performed for patients with
end-stage liver disease
 References
● Levinson, Warren (2016). Review of Medical Microbiology and Immunology. USA: McGraw-Hill Education

● Hinkle, J & Cheever, K. (2018) Medical – Surgical Nursing 14th Edition. China: Wolters Kluwer

● Ignatavicius & Workman (2016). Medical-Surgical Nursing, 8th Edition. St. Louis Misourri: Elsevier

● Centers for Disease Control and Prevention. Viral Hepatitis. Retrieved from

https://www.cdc.gov/hepatitis/abc/index.htm
 Thanks
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